• Donald A Kennerly, Rustam Kudyakov, Briget da Graca, Margaret Saldaña, Jan Compton, David Nicewander, and Richard Gilder.
• Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206.
• Health Serv Res. 2014 Oct 1;49(5):1407-25.

ObjectiveTo report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.Study SettingRecords from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.Study DesignWe examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.Data CollectionProfessional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).Principal FindingsEstimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.ConclusionsAEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.© Health Research and Educational Trust.

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